Dealing with Uncertainty

Doctor

Patient

Examination

Marking

Management

Doctor Information

Joan Humphries 31 years old

Past medical history: Healthy baby boy born 15 months ago

Current Medications: Cerelle 75mcg

Allergies: None known

Last consultation: 14 months ago: Seen by Dr Joyce - 4 weeks post partum, wanting to go back on oral contraceptive, Was doing well on cerazette prior to planned pregnancy, therefore wishes to go back on it. No Cotraindications, BP 120/75 today. Plan: start back on cheaper alternative Cerelle, pt happy with the swap.

Patient Information

Joan Humphries 31

Opening Sentence: I’m not feeling very well doctor, its all a bit vague I’m sorry, but I know something is not right here,

Information readily revealed: You gave birth to your son 15 months ago, and had been doing really well, but now you feel ‘weird’ for want of a better word. For the last 6 weeks, you’ve started to feel sickly, even vomiting once or twice. You’ve also noticed abdominal gripes, that appear to be random, but can be very uncomfortable. Your bowel habits have changed becoming more constipated, and difficult to pass. Your ‘water works’ have generally been ok, with the exception of 3 weeks ago, when you noticed blood in your urine, as well as an associated severe pain in the right side of your stomach. You were just about to call an ambulance, but it suddenly passed, and the bleeding stopped.

Information revealed only if asked: Your mood has not been the best the last month or two, you've noticed that you’re quick to snap at others, and that you are feeling a little sad. You've been quick to tears, when normally, you're quite stoical. You’ve had none of the following: PR bleeding, diarrhoea, tiredness, change in temperature sensation, weight change, change in appetite, vaginal discharge, or abnormal PV bleeding, suicidal ideations. You don’t have any periods on the cerelle (similar to the cerazette before it). You don’t think you could be pregnant as you take the cerelle religiously. If asked about the possibility of pregnancy, you will reveal that you had thought of this first, and have done several pregnancy tests, all of which have been negative. Social History: You live with your husband Mark, who is concerned by these ongoing symptoms. Your son Joseph is now 15 months old, he spends some of his days at nursery, others at home with you. You work part time as a teaching assistant. You don't have any financial problems, you don’t drink nor smoke any cigarettes. You enjoy walking outside, and regularly go for strolls with your son or as a family. You have a healthy and varied diet.

Ideas: The only thing that has changed is the cerelle, and you’re wondering if that could be the cause of your symptoms. Although you find it strange that you’ve been on it for so long and only recently noticed these problems, maybe the doctor can tell you if this is possible. Concerns: You are finding it difficult to work with your current symptoms, is there anything the doctor can do to aid you? you can’t go on like this. You’re also worried as its getting worse, incase its something sinister.

Mark scheme

Data Gathering

POSITIVE INDICATORSOrganised and systematic in gathering information from history taking, examination and investigationIdentifies abnormal findings or results and/or recognises their implicationsEnquires fully into red flags for depression and abdominal problems.Enquires about social history

NEGATIVE INDICATORSMakes immediate assumptions about the problem Intervenes rather than using appropriate expectant management Is disorganised/unsystematic in gathering information Data gathering does not appear to be guided by the probabilities of disease. Fails to enquire about red flags for depression / change in bowel habits

Clinical Management Skills

POSITIVE INDICATORSMakes appropriate diagnosisDevelops a plan for going forward, this need not necessarily include managing her symptoms, but should be sensible and safeMakes plans that reflect the natural history of common problems Management approaches reflect an appropriate assessment of risk - i.e. patient well no need fro admitting etc.Makes appropriate prescribing decisions

Manages risk effectively, safety netting appropriately

NEGATIVE INDICATORSFails to consider common conditions in the differential diagnosis Does not suggest how the problem might develop or resolve Fails to make the patient aware of relative risks of different approaches

Decides to admit or refer immediatelyFollow-up arrangements are absent or disjointed

Inter Personal Skills

POSITIVE INDICATORSIdentify patient’s agenda, health beliefs & preferences / does makes use of verbal & non-verbal cues.Works with the patient to develop a shared management plan or clarify the roles of doctor and patientUses explanations that are relevant and understandable to the patientShows sensitivity for the patient’s feelings in all aspects of the consultation including physical examination

NEGATIVE INDICATORSDoesn't enquire about patients ICETakes a doctor centered approach towards managementUses an explanation that is filled with jargon, or forgets to explain at allDoesn't show any sympathy / empathy towards the patient's situationFails to empower patient

Management

Diagnosis: This is a very difficult case, if you got the correct diagnosis, then excellent, if not don’t worry. This case is meant to be practice for a scenario where you may not know the diagnosis, but are still expected to manage the person / condition safely. It's very likely that in the CSA you may come across a case that you haven’t revised / been exposed to before. Therefore it’s always good to practice these types of cases, as even if you do not know the diagnosis you can still gather information, explore I.C.E and come up with a safe and sensible plan of investigations. Consequently, the marking for this case, is more heavily focussed around safe and effective data gathering / management of uncertainty, rather than achieving a correct diagnosis.

This case is modelled around a real life case, and it turned out that she had Primary Hyperparathyroidism, resulting in Hypercalcaeima - that was the cause of her symptoms.

Hypercalcaemia: (the following has been taken from NICE CKS)

Causes:

More common causes (accounting for 90% of people with hypercalcaemia):

Management:In this case you are uncertain for the mite being as to what the cause maybe, as the patient has not had any bloods taken. So whilst you may have your suspicions, at this time you have no firm diagnosis. So a safe management plan would include a pregnancy test to exclude this as a cause, followed by some blood tests. Most places have the facility now to send patients to the nearest center / hospitals to get bloods done that day or within the next few days (Make sure you request liver profile, alkaline phosphates, vitamin D, parathyroid hormone levels, thyroid stimulating hormone and T4 levels as well as urea and electrolytes). The patient may also need a CXR depending on what you suspect the cause to be (TB / sarcoidosis). As well as this, it would be important to book her a follow up appointment very soon, with excellent safety netting so that the patient knows what to do if anything worsens.

As for managing Hypercalcaemia:There appears to be some variation, and a lot will also depend on the suspected cause. NICE CKS would state that if the calcium is above 3.40, or the patient is symptomatic then you should consider admitting them. If they don't meet this criteria, then refer according to the results gained from your blood test. If you suspect primary hyperparathyroidism, or you simply don't know what the cause is, then an endocrinologist would be the most appropriate person to refer to. If you suspect cancer, then obviously fast track them on a 2 week wait. If renal failure is the cause, refer to renal etc...

If you are uncertain whether to admit or how to manage the patient, then you can always discuss with either the on call medical registrar / consultant, or even the endocrinology department at your local hospital.

If the patient is to be managed within the community, consider stopping any medications that may be increasing the calcium levels, or those that prolong the QT interval. Request an urgent ECG (or get one done in house) to exclude arrhythmia, or QT prolongation. Encourage the patient to drink plenty of fluids, and you could consider an oral bisphosphonate (depending on what the cause may be). If you are uncertain, please seek advice from the specialist.

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